NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is teaching a client with asthma about the use of a peak flow meter. Which of the following instructions should be included?
Correct Answer: B, C
Rationale: Recording the highest of three readings ensures accuracy, and cleaning the meter weekly prevents contamination.
Question 2 of 5
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.
Question 3 of 5
The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response should the nurse make to the family?
Correct Answer: A
Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.
Question 4 of 5
A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?
Correct Answer: D
Rationale: Decreased body temperature is not a cause of low sperm count; elevated temperatures, such as from saunas, can impair spermatogenesis, indicating a need for further teaching.
Question 5 of 5
A nurse is administering indomethacin to a neonate. To ensure that the nurse has identified the neonate correctly, the nurse should do which of the following? Select all that apply.
Correct Answer: A, C, D
Rationale: Correct identification involves checking the ID band against the medical record and date of birth, and confirming with parents.